Every finding on record at Homestead Hospice of Northwest Georgia, LLC

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted by the nurse surveyor that the initial bereavement risk assessment had not been completed as the part of the initial comprehensive assessment as required. For RRHV#2, the initial bereavement risk assessment was completed by the Medical Social Worker (MSW) 28 days after the initial MSW visit. For RRNHV#3, the initial bereavement risk assessment was completed by MSW, 21days after the initial MSW visit. Findings were verified by the Regional Clinical Specialist.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the nurse surveyor noted that the goals were not consistently measurable. For example, “Patient/Caregiver will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease by end of certification period”, and “Pain will be managed at acceptable level to patient throughout hospice stay”. There were minimal short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety, most time frames for completion were at end of certification period (or were not updated from recertification-to-recertification, RRHV#2) or “throughout hospice stay”. Finding was confirmed by the Administrator, and the Regional Education, Clinical Specialist and Branch Director.

Observed in Tracer Activities. The Volunteer Coordinator that was employed from second quarter 2021 to first quarter 2024 did not leave any documentation to support her efforts to recruit or retain volunteers during 2003 and the first two months of 2024. Additionally, the organization currently does not have any active volunteers. The active volunteers at the time left when the Volunteer Coordinator did (apparently they were friends). Attempts to hire another Volunteer Coordinator were ongoing after she left. One was hired but only lasted for one month. Another Volunteer Coordinator has been hired and has finished her onboarding. She is now finishing up her orientation and has already recruited six volunteers who are in the process of being onboarded. Finding was verified by the Administrator.

Observed in Tracer Activities. It was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for 2023, 2.05% and year to date 2024, 0.06%. Finding was verified by the Administrator. The organization does have a PIP in place. They have hired a new Volunteer Coordinator within the last month. She has experience and has already started the process of recruiting new volunteers.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted by the nurse surveyor that entries in the patient record were not appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. For RRHV#2, the patient’s Polst Form was signed by the POA but was not signed and dated by the physician. For RRHV#3, the patient’s Polst Form was signed by the physician but not dated. Finding was verified by the Branch Director.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#3 the backup E-tank was stored in a closed closet under hanging clothes in the back of the closet. Findings were verified by the Branch Manager who was present during the home visit. Upon record review, there was no specific documentation of teaching to support teaching regarding proper oxygen backup cylinder storage to caregiver.

Based on observations, clinical record reviews and staff interviews, it was determined that the interdisciplinary group failed to ensure that plan of care addressed specific, individualized interventions necessary for the palliation and management of the terminal diagnosis for 2 of 13 patients (P#) (#4 and #5). The findings were: 1. Review of the clinical record for patient #4 with an admission date of 7/2/21 and a diagnosis of cerebrovascular disease revealed the Registered Nurse (RN) visited the patient on 7/6/22 and documented the foley catheter was changed using a 18 french catheter. However, the clinical record lacked a physician's order for the care and maintanence of a foley catheter. During an interview on 8/24//22, at 12:00 p.m., the Administrative Assistant did provide an order for foley catheter care dated 8/24/22. The clincial record lacked a physician's order for the foley catheter change done on 7/6/22. The skilled nurse failed to obtain a physician's order for the care and maintanence of the foley catheter. 2. Review of the clinical record for patient #5 with an admission date of 5/19/22 and a diagnosis of Alzheimer's disease revealed the Registered Nurse (RN) visited the patient on 7/31/22 and doucmented wound care was provided to the right leg as follows: wound cleansed with wound cleanser and flagyl powder applied to area. However, the clinical record lacked a physician's order for the wound care provided. On 8/2/22, the RN provided wound care to the right heel as follows: cleansed with wound cleanser and duoderm applied, heel boots applied however, the clinical record lacked a physician's order for the wound care provided. During an interview on 8/24/22, at 12:00 p.m., the Administrative Assistant did provide an order for wound care dated 8/24/22. The clincial record lacked a physician's order for the wound care done on 7/31 and 8/2/22. The skilled nurse failed to obtain a physician's order for wound care provided on 7/31 and 8/2/22.

Based on clinical record review, it was determined that the interdisciplinary group failed to ensure that the plan of care was followed for frequency of visits provided in accordance with the patient's plan of care for 5 of 13 patients(P) (#1 #2, #4. #8, and #9) sampled patients who were current hospice beneficiaries. Findings include: 1. The interdisciplinary care plan review for patient (P) #4 with an admission date of 7/2/21 and a diagnosis of cerebrovascular disease required the hospice aide to visit the patient three (3) times a week. The interdisciplinary care plan reviews dated 7/13 and 7/27/22 reflected that there were no changes in the visit frequency for the aide. The clinical record indicates the aide only visited the patient one (2) times the week of 7/24/22 instead of 3 times as ordered. The record did contain a missed visit note dated 7/26 which inidicated the visit was missed due to no availabity of a hospice aide to complete the visit. The agency failed to ensure staffing was available to provide services as identified to meet the needs of the patient. During an interview with the Regional Director on 8/24/22 at 12:00 p.m., it was confirmed the agency staff failed to follow the ordered plan of care for the aide visit frequency. 2. The interdisciplinary care plan review for patient #8 with an admission date of 12/23/21 and a diagnosis of hypertensive heart disease required the hospice aide to visit the patient two (2) times a week. The interdisciplinary care plan reviews dated 7/13 and 7/27/22 reflected that there were no changes in the visit frequency for the aide. Documentation of aide visits revealed that the aide did not visit the patient on the week of 7/26/22 and only visited the patient 1 time the week of 6/26/22. The record did contain a missed visit note dated 7/14/22 which indicated the visits were missed due to no availabity of a hospice aide to complete the visit. The agency failed to ensure staffing was available to provide services as identified to meet the needs of the patient. During an interview with the Regional Director on 8/24/22 at 12:00 p.m., it was confirmed the agency staff failed to follow the ordered plan of care for the aide visit frequency. 3. The interdisciplinary care plan review for patient #9 with an admission date of 12/18/18 (closed record) and a diagnosis of Alzheimer's Disease required the hospice aide to visit the patient 2 times per week. Documentation of hospice aide visits revealed that the aide only visited the patient 1 time a week during the weeks of 7/14 and 7/26/22. The record did contain a missed visit note dated 7/26/22 which inidicated the visit was missed due to no availabity of a hospice aide to complete the visit. The agency failed to ensure staffing was available to provide services as identified to meet the needs of the patient. During an interview with the Regional Director on 8/24/22 at 12:00 p.m., it was confirmed the agency staff failed to follow the ordered plan of care for the aide visit frequency. . 4. The care plan review for patient (P) # 1, with an admission date of 7/21/21 and a diagnosis of cerebrovascular disease, required the hospice aide to visit the patient three times a week. A review of the patient's chart revealed visits for the dates 4/25/22 through 5/16/22. The agency failed to ensure staffing was available to provide services as identified to meet the needs of the patient. During an interview with the Regional Director on 8/24/22 at 12:00 p.m., it was confirmed the agency staff failed to follow the ordered plan of care for the aide visit frequency. . 5. The care plan review for patient (P) # 2, with an admission date of 5/25/22 and a diagnosis of Liver Disease, required the hospice aide to visit the patient two times a week. The care plan was reviewed for the dates 6/30/22 through and 7/22/22, which reflected that there were no changes in the visit frequency for the aide. The clinical record indicates the aide only visited the patient one time during the reviewed time frame instead of two times as ordered. The record did contain a missed visit note dated 7/14/22. The agency failed to ensure staffing was available to provide services as identified to meet the needs of the patient. During an interview with the Regional Director on 8/24/22 at 12:00 p.m., it was confirmed the agency staff failed to follow the ordered plan of care for the aide visit frequency.

Based on review of clinical records and staff interviews, it was determined that the hospice failed to ensure compliance with policy regarding the destruction of controlled drugs in the home following the patient's death for 2 of 2 (#12 and #13) sampled patients (P). Findings were: 1. The bereavement record for Patient (P) #12 reflected that the patient received hospice services in the home setting from 12/26/21 to 12/27/21 and the patient was prescribed controlled medications which were identified on the medication profile. Documentation of a pronouncement form reflected the patient died at home on 12/27/21. However, the clinical record lacked documentation of drug destruction. The clinical record contained a skilled nurse note dated 12/27/21 which stated morphine and Ativan were disposed of in soap dish. The clinical lacked documentation of how much medication was destroyed and a dated signature of the nurse and witness. According to agency policy 407. labeled: Disposing of Controlled Drugs, at the time of the destruction, the following information is documented in the patient's clinical record: name and dose of medication, amount or quantity of the medication remaining and destroyed, dated and manner of disposal and dated signature of the nurse and witness. The agency failed to follow their policy and procedure for the destruction of controlled drugs. During an interview with the Regional Director on 8/24/22 at 12:00 p.m., it was confirmed the agency staff failed to follow policy and procedure for drug disposal. 2. The bereavement record for Patient (P) #13 reflected that the patient received hospice services in the home setting from 9/22/21 to 10/12/21 and the patient was prescribed controlled medications which were identified on the medication profile. Documentation of a pronouncement form reflected the patient died at home on 10/12/21. However, the clinical record lacked documentation of drug destruction. The clinical record contained a skilled nurse note dated 10/12/21 stating the family will dispose of the controlled medications. According to agency policy 407. labeled: Disposing of Controlled Drugs, in the event the patient/caregiver refuses to allow medications to be destroyed the refusal is documented in the patient's clinical record with the name and strength of the medication and the amount remaining, Included with the documentation is the patient/caregiver's signature attesting to the refusal and the date the attending or hospice physician was notified of the refusal. During an interview with the Regional Director on 8/24/22 at 12:00 p.m., it was confirmed the agency staff failed to follow policy and procedure for drug disposal.